Pelvic floor

The pelvic floor muscles support the bladder, the womb and the bowel. They are the muscles you squeeze to stop yourself passing urine, which is how Urdu names them: peshaab rokne wale patthe.

When those muscles weaken, two things can happen. Urine can leak, and the organs they hold up can drop.

Women's Health Concern and NHS inform, the Scottish health service's site, both describe two main types of leaking. Stress incontinence is leaking when the bladder is under pressure, such as when you cough, laugh or sneeze. Urge incontinence is a sudden, strong need to go, with leaking before you get there.

A prolapse is when the womb, bladder or bowel bulges down into the vagina. The NHS website says it is common in women over 50, and the European Menopause and Andropause Society (EMAS) says nearly half of women will develop some degree of prolapse, with symptoms getting worse after the menopause.

The NHS lists the signs of a prolapse as a feeling of heaviness, discomfort or pressure low in the tummy or vagina, a bulge or lump you can feel or see, pain or numbness during sex, problems opening the bowels such as constipation, and bladder changes: feeling it has not fully emptied, needing to go more often, or leaking a little when you cough, sneeze or exercise.

A prolapse does not always cause symptoms. The NHS says it is sometimes found during a test for something else, such as a smear test.

The NHS website names pregnancy and childbirth among the causes of prolapse, and NHS inform lists pregnancy and vaginal birth among the things that raise the chances of leaking. For women who had several children, that history is part of the picture decades later.

Then comes the menopause. On prolapse the NHS website says: "It's more common as you get older, particularly after the menopause." The Pakistan Menopause Society's recommendations list stress urinary incontinence among the genitourinary symptoms of the first years after the menopause (Table 1).

The NHS also names being overweight, long-term constipation and straining, a cough that will not go away, and pelvic surgery such as a hysterectomy among the causes of prolapse.

• Pelvic floor exercises. The NHS website lists them as a treatment for prolapse, usually with a specialist women's health physiotherapist, and NHS inform lists them among the first treatments for leaking. NHS inform also has a guide to finding and exercising them (linked in the sources). A physiotherapist can tailor the exercises to you.
• The causes you can do something about. Being overweight, long-term constipation and a persistent cough are each worth raising with your doctor. See weight management.
• Drinks. NHS inform suggests avoiding or cutting down on alcohol and caffeinated drinks, such as tea, coffee and some fizzy drinks, and EMAS lists caffeine and alcohol among the things linked to leaking. If the kettle goes on all day, see chai and caffeine.
• Strength more widely. The PMS recommendations list body-weight and resistance exercise for women at the menopause (Table 6). See strength training.

For a prolapse that is bothering you, the NHS website lists hormone treatment as a vaginal cream, tablet or ring, a vaginal pessary (a small plastic or silicone device that supports the organs), physiotherapy with pelvic floor muscle training, and surgery if the prolapse is severe. It says not every prolapse needs treatment, and that you and your doctor decide together. For leaking, NHS inform lists bladder training, and medicines or surgery for some women if the first treatments do not work.

NICE NG23 points doctors to its separate guideline on urinary incontinence and prolapse for women who have both genitourinary symptoms and an overactive bladder, including the use of vaginal estrogen (1.5.12). EMAS says vaginal estrogen may also help with leaking.

NHS inform says to speak to your GP practice about any symptoms of urinary incontinence. If you have symptoms that could be a prolapse, the NHS website says a GP will ask about them and examine you, and that you can ask for the examination to be done by a female doctor and for a chaperone to be in the room.

The PMS recommendations ask doctors to refer women with prolapse symptoms, and to investigate leaking that affects quality of life, urine infections that keep coming back, or blood in the urine (Tables 2 and 4).

Leaking can sit heavily on a woman who prays five times a day, because questions of purity and wudu come with it. Women ask about this, often privately. Those questions belong with a qualified scholar.

At home, leaking is easy to hide and hard to talk about. If a sister or your mother has the same problem, saying so out loud may be the push one of you needs to see a doctor.